On-line version ISSN 2078-5135Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.99 n.12 Cape Town Dec. 2009

To the Editor: All doctors in private practice should be well aware that the National Health Insurance (NHI) scheme is a clear and inevitable danger. To judge from the comments of ANC luminaries, the government will probably do its usual bull-in-a-china-shop act by ramming the bill through parliament without much regard for the opinions of other stakeholders. And if the government's past form in handling health care is anything to go by, implementation of NHI in South Africa is likely to be a disaster.

With this sword hanging over our collective heads, the lack of any real debate or innovative thinking among doctors in private practice is quite astounding. The prohibitive cost of the system has indeed been pointed out, that many or most young doctors will emigrate, and that health care delivery via the NHI will be sadly ineffective  as is generally the case with state-run systems. But, so far, the ANC has given every indication that these arguments will have little influence on their decision.

Is there anything that we (and by 'we', I mean all doctors in private practice) can do to avert the coming disaster?

I believe that an important first step is to realise that unbridled medical consumerism, as is practised in South Africa today, is something that should be of the past. Globally, societies are moving away from it; even in the USA, the very heartland of capitalism, the Obama administration is trying to improve the wasteful and ineffective health care system, where a sizeable minority have no medical care at all. In South Africa, with its preponderance of indigent people, the status quo is all the more unsustainable. Let us therefore accept that changes are inevitable.

For private practice to survive, compromises will have to be made, and perhaps some profound ones at that. As an example of what I mean, consider the following suggestion: that we volunteer to help in state hospitals for a certain time period each week. It would hardly be deleterious for a practitioner to spend, say, 3 hours a week caring for indigent patients, and it could send out a powerful and positive message. Imagine what a difference it would make if private practitioners assisted widespread in public facilities, working with their characteristic efficiency! (It may also help us to rediscover our roots as doctors  the establishment of a mini-Médecins Sans Frontières )

In addition, a gesture like this could just make the implementation of NHI superfluous or, at the very least, give us more bargaining power. I must stress, however, that (i) to achieve any meaningful results, such a scheme would have to be implemented on a large scale, with every private practitioner getting involved (granted, it might not be all that voluntary); and (ii) we will have to think of further ways to tackle the problem.

Obviously, all the other stakeholders in the health care industry will have to contribute. Private hospitals, pharmaceutical companies and well-off medical aid companies will, in the interests of their own survival, have to make some compromises.